Medical Records Clerk

Job Description

<p><strong><u>Job Summary</u></strong></p><p><br></p><ul><li>Responsible for carrying-out all procedures as they relate to the organization of all patient medical record files.</li><li>Responsible for assembly and analysis (OP / IP), loose report filing, creating new folders after the discharge of the patient. To ensure that each in-patient medical records contains necessary documentation, reports, tests results, or other required elements as per departmental policy based on CBAHI &amp; JCIA standards.</li><li>Retrieve record as requested.</li><li>Responsible for notifying all physicians of their incomplete medical records monthly to comply with hospital policy. All queries from Physicians are referred to this policy.</li><li>Proper file maintenance has to be maintain in the master record filing area.</li><li>Auditing of files will be carried-out.</li></ul><p><br></p><p><br></p><p><br></p><p><strong><u>Major Duties and Responsibilities</u></strong></p><p><strong> </strong></p><p>Outpatient Record Retrieval / Filing</p><p><br></p><ul><li>Retrieves all medical records upon request (walk-in patients and ER patients)</li><li>Retrieves pre-appointment records for next day outpatients visits and filing of the visited patients record in permanent filing area.( 1 st &amp; 2nd shift, i.e. 08:00 — 16:00 &amp; 16:00 -</li><li>Reviews and assembles all patient files after retrieval.</li><li>Prepares medical record folders for new patients.</li><li>Inserts all incoming reports throughout each shift to prevent backlog.</li><li>Maintains all shelving areas in accurate terminal digit order by periodically performing file audits.</li><li>Complies with all departmental the policies and procedures.</li><li><br></li><li>Routing the records to the outpatient and inpatient departments when it’s urgently needed for the patient care.</li><li>Maintains accurate, neat files in a timely manner.</li><li>Maintains confidentiality, security and personal privacy of all patient information and files.</li><li>Places records on appropriate shelving area, i.e. permanent filing area, incomplete, coding and etc.</li><li>Assembly and Analysis</li><li>Responsible for collection of medical records discharges not forwarded to Medical Record Department.</li><li>Assemble the unorganized document according to the standard assembling order (CBAHI &amp; JCIA standard) of the discharged patient’s records.</li><li>Analyze the medical record file for missing documents as per policy.</li><li>Assigned to every physicians responsible for dictation of Surgical Procedure Report and Discharge Summary.</li><li>Maintains accurate, neat files in a timely manner.</li><li>Maintains confidentiality, security and personal privacy of all patient information and files.</li><li>Maintains the computerized Medical Record Deficiency system.</li><li>Work is conducted in a professional manner maintains patient / staff confidentiality when required.</li><li>Participates in on-going education program developed by the department, e.g. department polices and procedures, Fire and Safety, Risk Management, Environmental control.</li><li>Assembly and Analysis</li><li>Responsible for collection of medical records discharges not forwarded to Medical Record Department.</li><li>Assemble the unorganized document according to the standard assembling order (CBAHI &amp; JCIA standard) of the discharged patient’s records.</li><li>Analyze the medical record file for missing documents as per policy.</li><li>Assigned to every physicians responsible for dictation of Surgical Procedure Report and Discharge Summary.</li><li>Maintains accurate, neat files in a timely manner.</li><li>Maintains confidentiality, security and personal privacy of all patient information and files.</li><li>Maintains the computerized Medical Record Deficiency system.</li><li>Work is conducted in a professional manner maintains patient / staff confidentiality when required.</li><li>Participates in on-going education program developed by the department, e.g. department polices and procedures, Fire and Safety, Risk Management, Environmental control.</li></ul><p><br></p><p><br></p><p><u>Qualifications:</u></p><p><br></p><ul><li>Diploma in Medical Record Science / Technology</li></ul><p><br></p><p>Experience:</p><p><br></p><p>At least three 1 years experience working in Medical record department performing Technical tasks.</p><p><br></p><ul><li>Special requirements/skills:</li></ul><p><br></p><p>Fluency in verbal and written English.</p><p><br></p><p>Must possess complete familiarity with required medical record documentation, medical terminology, Anatomy, Physiology and Pathology.</p><p><br></p><p>Must possess thorough comprehension of the HMIS system as it relates to the medical records department and utilize that knowledge for practical applications.</p><p><br></p><p>Ability to operate computerized health information system as required by departmental functions.</p><p><br></p><p>Ability to understand diverse documentation styles.</p><p><br></p><p>Exhibits professionalism and excellent interpersonal communication skills.</p><p></p>